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Author: arrete Big funky green star, 20000 posts Old School Fool Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: of 744329  
Subject: Reflections of a Medical Ex-Practitioner Date: 4/8/2013 9:32 AM
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Dr. Marsh now raises Christmas trees in Ipswich, Mass.

>> A fundamental principle in medicine is that if you get the diagnosis wrong, you'll probably apply the wrong therapy. A corollary is that if the therapy isn't working, increasing the dose may make things worse. That's where we are with ObamaCare.

There are shortcomings aplenty in the health-care field, and changes and improvements are required. But never have I seen so many good intentions leading irreversibly to hell.
.....
Then, in the mid-1970s, things changed, and we became enlightened. Third parties, typically the insurance companies, were interpolated between the physician and the patient. Some of the consequences were unfortunate.

Patients knew that any suggestions I might make would have negligible consequences for their own budgets, so "more" became the expectation. A sense of entitlement developed. Why would the doctor hesitate to do some procedure, or hesitate to request a test? Everything was already paid for.
.....
The medical economist Rashi Fein observed in 1986 that there are only three ways to limit the extravagant demand for medical care: "Inconvenience," the practice used in the military, where one must wait interminably for care. "Rules," the third-party approach by which layers of rules and thousands of regulations are devised, most recently in a fool's quest to contain costs under ObamaCare. And "Price." This last option elicits gasps and chest-clutching from bien pensants who insist that all financial impediments to care must be removed. Yet it has one incontestably beneficial attribute: It requires the physician to study the true cost and benefits of a course of action, and then to present that data to the patient. Who is better suited than the patient to assess the value to him of the proposed treatment? Kathleen Sebelius? You gotta be kidding. <<

http://online.wsj.com/article/SB1000142412788732478950457838...

arrete - I thoughthe bit about the Christmas trees was the funniest
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Author: JLC Big gold star, 5000 posts Old School Fool Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 677113 of 744329
Subject: Re: Reflections of a Medical Ex-Practitioner Date: 4/8/2013 3:29 PM
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I learned to play for time by waiting, when it was safe to, before ordering an X-ray or a test—and to substitute less-expensive medications for more costly ones wherever possible.

Unfortunately this is a seriously lost art.

There is a "scam" currently going on at my hospital. It basically involved technology. The primary care physician doesn't get paid for a thorough history and physical, so they punt it over to the specialist. The specialist gets paid to "do things" instead of a thorough history and physical.

So opposite of when I was in residency (20 years ago) when I did an elective with a specialist. He said he only did procedures to confirm the presence of one or two diseases. The rest were proven in the history and physical.

JLC

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Author: bighairymike Big gold star, 5000 posts Old School Fool Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 677130 of 744329
Subject: Re: Reflections of a Medical Ex-Practitioner Date: 4/8/2013 4:37 PM
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And "Price." This last option elicits gasps and chest-clutching from bien pensants who insist that all financial impediments to care must be removed. Yet it has one incontestably beneficial attribute: It requires the physician to study the true cost and benefits of a course of action, and then to present that data to the patient.

In todays convoluted system, how does anyone come up with "the" true cost, one that the patient can rely on. Spend a couple days in the hospital and you will be getting bills from providers you never heard of, for services you aren't sure what they are, and then there's the 500 line item invoice from the hospital for every doctor visit, bandaid and aspirin you had while there.

How can a doctor <or anyone for that matter> get all the necessary information together from all the diverse sources for presentation to the patient? Maybe what is needed is bundled services and advertised prices.

Who is better suited than the patient to assess the value to him of the proposed treatment? Kathleen Sebelius? You gotta be kidding.

How are the patients that JLC writes about going to assess the value of this data when they can't even figure out how to stop having babies. And whose gonna pay for it anyway, because they sure aren't.

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Author: isawbones Big red star, 1000 posts Top Recommended Fools Old School Fool Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 677172 of 744329
Subject: Re: Reflections of a Medical Ex-Practitioner Date: 4/9/2013 9:52 AM
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I think the whole point of the article is that the patient needs to have "skin in the game." ie. be concerned about the cost of the care he is requesting and think or ask about less expensive alternatives which is his choice to begin with. Obamacare further distances the patient from the actual cost of things.

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Author: JLC Big gold star, 5000 posts Old School Fool Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 677226 of 744329
Subject: Re: Reflections of a Medical Ex-Practitioner Date: 4/9/2013 5:44 PM
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Maybe what is needed is bundled services and advertised prices.

Be careful what you wish for.

Right now there is an attempt on several fronts to bundle hospital based physicians: mostly anesthesiologists, radiologists, and ER. Each patient the comes to the hospital gets charged $X whether they use those services or not. Insurance companies would then just send one big check to the hospital.

Sounds hunky-dorey for the consumer, one less thing. For your's truly, it is bad for two reasons. One, it essentially makes me a hospital employee. Which at that point, I'd retire or fake a disability. Want to get me stirred up, have some pencil pushing geek tell me what, when, and where to do something that they no absolutely nothing about. Two, it then makes groups of physicians fighting with each other about how big their piece of the pie should be. And then you actually have to get the money from the hospital. And that isn't easy, DW's group is owed $$$ by a couple hospitals in this area. They are considering legal action is in placing a lein.

Think you have a physician shortage now, implement something like that.

JLC

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Author: CCinOC Big funky green star, 20000 posts Top Recommended Fools Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 677230 of 744329
Subject: Re: Reflections of a Medical Ex-Practitioner Date: 4/9/2013 6:05 PM
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JLC wrote: Want to get me stirred up, have some pencil pushing geek tell me what, when, and where to do something that they no absolutely nothing about

Well, they've done it in the mortgage industry.

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Author: warrl Big funky green star, 20000 posts Old School Fool Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 677240 of 744329
Subject: Re: Reflections of a Medical Ex-Practitioner Date: 4/9/2013 8:28 PM
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In todays convoluted system, how does anyone come up with "the" true cost, one that the patient can rely on. Spend a couple days in the hospital and you will be getting bills from providers you never heard of, for services you aren't sure what they are, and then there's the 500 line item invoice from the hospital for every doctor visit, bandaid and aspirin you had while there.

On one of DW's outpatient surgeries, I swear, we got three separate bills from the hospital (plus one from the doctor and one from the anesthesiologist). The three separate bills were for the operating room, the recovery room, and housekeeping on those two rooms.

Yes, they charged us for using the rooms and also for having the rooms cleaned.

What I figured out is that by breaking things up in so many pieces, most of the individual costs that they actually incur can be put on at least two bills each.

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Author: bighairymike Big gold star, 5000 posts Old School Fool Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 677247 of 744329
Subject: Re: Reflections of a Medical Ex-Practitioner Date: 4/9/2013 9:24 PM
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Right now there is an attempt on several fronts to bundle hospital based physicians: mostly anesthesiologists, radiologists, and ER. Each patient the comes to the hospital gets charged $X whether they use those services or not. Insurance companies would then just send one big check to the hospital.

Sounds hunky-dorey for the consumer, one less thing. For your's truly, it is bad for two reasons. One, it essentially makes me a hospital employee. Which at that point, I'd retire or fake a disability. Want to get me stirred up, have some pencil pushing geek tell me what, when, and where to do something that they no absolutely nothing about. Two, it then makes groups of physicians fighting with each other about how big their piece of the pie should be. - JLC


----------------

I get your point but how else can you introduce some competition back into the system. It has to include price awareness of some sort. If not the hospital, then who else is in any reasonable position to aggregate the component costs? Somebody has to provide a quote to the customer and that ought to be the same entity that recieves payment. How else can there be accountability to get the costs right.

I don't claim to have the answers but all the talk seems to be about providing insurance coverage which is an entirely different topic than discussing how to lower the costs of providing health care in the first place (eg, tort reform, selling insurance across statelines, etc).

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Author: bighairymike Big gold star, 5000 posts Old School Fool Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 677250 of 744329
Subject: Re: Reflections of a Medical Ex-Practitioner Date: 4/9/2013 10:08 PM
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>>In todays convoluted system, how does anyone come up with "the" true cost, one that the patient can rely on. Spend a couple days in the hospital and you will be getting bills from providers you never heard of, for services you aren't sure what they are, and then there's the 500 line item invoice from the hospital for every doctor visit, bandaid and aspirin you had while there.<<

On one of DW's outpatient surgeries, I swear, we got three separate bills from the hospital (plus one from the doctor and one from the anesthesiologist). The three separate bills were for the operating room, the recovery room, and housekeeping on those two rooms.

Yes, they charged us for using the rooms and also for having the rooms cleaned.

What I figured out is that by breaking things up in so many pieces, most of the individual costs that they actually incur can be put on at least two bills each. - warrl


--------------------------

I don't see how an individual patient can ever stand up to this invoicing onslaught. Only the insurance companies can have the necessary systems and computing horsepower to digest all this data. Which they do and reflect the homogenized cost in the premiums they charge for their various products. That seems like fundamentally a pretty good system to me. We should strive to make it more efficient, eg marketing products across state lines.

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Author: JLC Big gold star, 5000 posts Old School Fool Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 677267 of 744329
Subject: Re: Reflections of a Medical Ex-Practitioner Date: 4/10/2013 11:18 AM
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I get your point but how else can you introduce some competition back into the system.

Get the government OUT of the system.

It has to include price awareness of some sort.

Get the government AND other third party payers out of the system. IMHO, the main problem with health insurance, it has been mutated into something it was never intended to be. You don't use your car insurance for oil changes nor home insurance to clean your carpets, it is for big financial set backs. If you had everyone in high deductible HSA plans, consumers would become more aware and would demand pricing options upfront.

You do see some attempts such as this system in Oklahoma

http://reason.com/reasontv/2012/11/15/the-obamacare-revolt-o...

and I see it locally in a "doc in the box" set up.

http://www.velocitycare.com/index.php?src=&submenu=

Can't find the listing online but they used to advertise prices for various services.

There are answers out there, but government is still the biggest distortion.

JLC

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Author: lowstudent Big funky green star, 20000 posts Old School Fool Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 677269 of 744329
Subject: Re: Reflections of a Medical Ex-Practitioner Date: 4/10/2013 11:30 AM
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There are answers out there, but government is still the biggest distortion.

_______________________________

Much like in banking, the distortion of bad government intrusion, is so comprehensive that it is almost impossible to even see the problems.

Each solution revolved around fixing the government involvement and never acknowledges that involvement may very well be the problem(as you I and many other believe)

That is my problem with much if not most government expansion. It is not that there is not a role for government, but that the role of government unless tightly controlled with 'thou shall not' legislation expands

Of course, the courts rule that the 'thou shall not' clauses really don't count after a while.

The problem is rather severe and the solutions will be draconian it appears, for we are unwilling to try to actually find the problem before we 'solve' it(never a good idea)

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Author: JLC Big gold star, 5000 posts Old School Fool Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 677273 of 744329
Subject: Re: Reflections of a Medical Ex-Practitioner Date: 4/10/2013 11:43 AM
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Well, they've done it in the mortgage industry

And we've seen how well that turned out.

JLC

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Author: beaconclks Big red star, 1000 posts Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 677284 of 744329
Subject: Re: Reflections of a Medical Ex-Practitioner Date: 4/10/2013 12:36 PM
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I get your point but how else can you introduce some competition back into the system. It has to include price awareness of some sort. If not the hospital, then who else is in any reasonable position to aggregate the component costs? Somebody has to provide a quote to the customer and that ought to be the same entity that recieves payment. How else can there be accountability to get the costs right.
______________________________________

Actually that "solution" doesn't do anything to bring competition back into the system. The amount of money in any healthcare "encounter" or transaction (e.g., gallbladder surgery), is essentially fixed. The third-party payer(s) are only going to reimbursement a set amount based on services rendered. So ultimately it has become a fight for a larger piece of the booty. This "solution" does nothing to lower cost, it just shifts POWER to the hospitals and away from the physician.

Typically, even hospital-base physicians are reimbursed for professional services the same way any other physician are, i.e., submit their bills to the third-party payers, get paid +/- the deductible and copay. These days, the misunderstanding by a lot of people is that doctors actual set their own fees. They absolutely do not...not even close. Each year all the various third-party payers---insurance companies, Medicare/Medicaid mostly---notify every physician what their particular fees are going to be for any given service provided. Same for hospitals, although hospitals actually get to negotiate just like other employers. Supposedly the third-party payers determine these rates based on actuarial analysis and then negotiations with the business community. Insurance companies compete with each other for contracts with as many employers as possible. Once the fees are negotiated, the insurance companies send out the new reimbursement rates to the various physicians that participate in those plans. Physicians have nothing to do with setting rates and they're the last ones to know what they're going to be. The physicians' only role at this point is to "opt-in" or "opt-out" of any given insurance product or plan. If the reimbursement rates for a particular plan are too low, where the fees are below the cost of doing business, they sometimes are forced to "opt-out". But then, of course, the ones that "opt-out" are excluded from treating the patients in those plans, which may or may not be a significant number of potential patients.

Medicare/Medicaid are obviously run by the federal and state governments and they also set their own rates but, of course, their rate-setting procedures are by nature FUBAR. So rates are never set by the physician.

When hospitals negotiate themselves between the physician and the payer, it's not to lower costs at all. It's to gain control of the "package" of money per patient encounter or transaction. Remember it's essentially a finite amount of money. So then it become all about who gets to divide up the "package". Well, the stupid clowns in the hospital administration get to decide how the money is doled out to the various hospital-based physicians and to themselves. Guess who gets the schitty end of the stick......it's not the hospital. So this particular solution only shifts the power and therefore the percentage of distribution of fees so the hospitals get more and physician get a smaller piece of the "package". Hospitals are not only generally stupid, they are very ruthless and greedy. Typically, hospital administrators are the bottom of the barrel as far as business people go. They only survive because there is limited competition and most hospitals are tax-exempt. Most of these idiots, if working in the real world of competitive business, would bankrupt a company within a year if not fired first.

With shrinking reimbursements to all medical providers, hospital and physician alike, all the players are trying to get the upper hand or advantage. Hospitals are more effective because they're better organized, have better lobbyists, and have incestuous relationships with the power-payers. Physicians are generally ineffective in business negotiations and management and act in an unorganized fashion most of the time. They are rarely proactive and react in response to "fear and greed". Consultants always describe business dealings with physicians being like herding a bunch of frightened squirrels. It's our own fault really.

Hospital-based physician groups have little power these days anyway. To get exclusive contracts with a hospital, they usually have to almost sell their souls. They have no leverage other than to walk away.....and if they do, where will they go? There are very limited jobs available outside of hospitals. Usually by contract, hospital-based groups are required to participate in ALL insurance plans the hospital itself participates in, and I can understand that. So those physicians groups don't even have the option non-hospital-based physicians have, i.e., refuse to participate in low-reimbursement plans. No matter what the reimbursement is, the hospital-based group has to accept it.

Sadly and in reality, behind closed doors, many hospitals already negotiate hospital-based groups' reimbursements by proxy with insurance companies. They essentially "trade" our fees for better fees for the hospitals. The administrators arrange (privately) for higher reimbursements for themselves in exchange for lower reimbursements for the hospital-based doctors. By the time the hospital-base docs get their rates, they have no idea that the rates are so low because the hospital administrator sold them out in exchange for better reimbursements for themselves.

Anyway, I don't how to solve the problem either. But the moron politicians will never solve the problem.

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Author: Art53 Big funky green star, 20000 posts Old School Fool Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 677291 of 744329
Subject: Re: Reflections of a Medical Ex-Practitioner Date: 4/10/2013 1:34 PM
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"The physicians' only role at this point is to "opt-in" or "opt-out" of any given insurance product or plan. If the reimbursement rates for a particular plan are too low, where the fees are below the cost of doing business, they sometimes are forced to "opt-out"." - beaconclks



If they were anything like me they'd take the path of least resistance. That's the Taoist way of doing things. Whatever requires the least amount of effort for the most reward.

Work for a private practice or Physician group. Work 3 days a week and collect a big paycheck and spend the rest of the week playing and having fun.

That's pretty much how I've lived my whole life.

Art

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Author: beaconclks Big red star, 1000 posts Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 677305 of 744329
Subject: Re: Reflections of a Medical Ex-Practitioner Date: 4/10/2013 4:37 PM
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If they were anything like me they'd take the path of least resistance. That's the Taoist way of doing things. Whatever requires the least amount of effort for the most reward.

Work for a private practice or Physician group. Work 3 days a week and collect a big paycheck and spend the rest of the week playing and having fun.

That's pretty much how I've lived my whole life.

Art

_______________________________________________

That's good advice. Do what makes you happy if possible.

Virtually all hospital-based physicians do work for a private physician group. Except for certain regions of the country, it's rare it find many "solo" practitioners in hospital-based practices (though there are some). Naturally, the hospital wants to negotiate and work with one group for each department (radiology, pathology, anesthesiology, radiation therapy and sometimes emergency room). The hospital has to provide these services 24/7/365 and it's much easier to insure backup coverage for sickness, vacations, etc., as well as insure adequate staffing, to deal with a representative from one group than 10, 20, or 30 different independent "solo" practitioners doing their own thing. It's especially important when something goes wrong or service is inadequate, as it makes it real easy to assign blame.

All physician groups, including hospital-based groups have a particular "culture", naturally derived from the collective personalities of the individual members. Some groups want to work very hard, run on very minimal staffing which maximizes income (to the extent possible). Other groups employ more providers (divides the group's collective income more ways), and enjoy more free time with family and friends, etc.

The most irritating and exhausting aspect of practice is usually being "on call", i.e., covering nights, weekends, and holidays. The only way to dilute the number of "on calls" to a tolerable level is to have more employed providers that "take call". Few groups appreciate employing "part-time" providers that only work a few days/wk and then only day hours, without sharing call. They'd rather hire full-time providers that share call. If the groups do hire part-time providers, since they're only working "easy hours", they are paid significantly less on a per hour basis than those providers that work the whole spectrum.

Also, the only source of income for the physician group is their fees for services provided, which are derived directly from reimbursements for services. Therefore reimbursement rates ultimately determine the income to the group, which determines how much each doctor earns. The volume of work going through the hospital each year is independent from how the physician groups are "managed". The work has to get down by someone, so if somebody is only working a few days/wk, that means the group has to hire others to work in their place when there off enjoying themselves. More employees mean more cost and lower incomes per provider. So working fewer days/wk, is incompatible with "big paychecks".

Life is funny that way.

But otherwise I agree wholeheartedly.

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Author: Art53 Big funky green star, 20000 posts Old School Fool Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 677308 of 744329
Subject: Re: Reflections of a Medical Ex-Practitioner Date: 4/10/2013 4:50 PM
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"More employees mean more cost and lower incomes per provider. So working fewer days/wk, is incompatible with "big paychecks". Life is funny that way. But otherwise I agree wholeheartedly." - beaconclks
---------------------------


Time is money. So it's a trade-off what you want out of life. You can't take it with you and one thing is for sure..... you aren't going to live forever. We all have a very limited amount of time on this earth.

So the question is, how much money does someone really need to live on? If it were me I'd be trying to figure out how to skin the rabbit. Figure out the balance that makes me the happiest.

Art

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Author: beaconclks Big red star, 1000 posts Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 677314 of 744329
Subject: Re: Reflections of a Medical Ex-Practitioner Date: 4/10/2013 5:55 PM
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Time is money. So it's a trade-off what you want out of life. You can't take it with you and one thing is for sure..... you aren't going to live forever. We all have a very limited amount of time on this earth.

So the question is, how much money does someone really need to live on? If it were me I'd be trying to figure out how to skin the rabbit. Figure out the balance that makes me the happiest.

Art

________________________________________

Art, you are so right.

Part of the reason why I retired from active practice (besides Bozocare), is because my goals in life had changed and the goals were inconsistent with the culture any of the groups here in my city.

It so happens that the groups in my city are mostly made up of docs that are in their 30's and 40's. Most are still raising families or paying for college for their kids. These docs, along with their spouses, family, and friends have very high, unrealistic expectations of what their lifestyle should be. They're all out of sync with the new paradigm in today's medicine, an ever (d)evolving paradigm that's been developing over the last 30 years and accelerating.

For a variety of reasons related to the above, they either want to or have to maintain a certain income. When your prices (fees) are fixed and out of your control, your costs are continuing to rise, the only way to maintain your income level is to work longer hours and run your staffing "lean and mean". These docs employ the bare minimum providers so they don't have to divide the pie as many ways.

When you get a bunch of these younger, energetic, docs with big school loans, and a lifestyle "acceptable" to themselves, their spouses, kids, and family....including the spouse's family, they're willing to work their arses off. They really believe that by doing that, they'll get ahead, and some do. But most simply raise their spending to match or exceed their income. So even though they're earning a respectable income, they're really not "rich" either in terms of wealth or happiness. They're always working and always stressed.

They're usually miserable at work because being "almost" short-staffed most of the time means everybody works much harder, nobody's available for lunch or coffee breaks, and they also take more call. In addition, service to the hospital, other physicians, and patients can many times be borderline inadequate or just plain inadequate. This makes for very a cranky, stressful work environment which is already stressful enough because of the nature of the work, demanding colleagues, and impatient administrators.

As you know, time flies (especially when you have your head down working), kids grow up way too fast, and suddenly they're in their late 50's, early 60's, their kids are grown (productive or criminal), they may or may not be divorced, their health isn't as good, and they've missed out on the best things in life, all to live up to an expectation mostly demanded by other people.

My (and especially my wife's) personality and goals are no longer compatible with this approach to life. I've tried to talk a few of these groups into letting me work part-time, but within their groups, their culture is "pedal-to-the-metal" all the time with no room or tolerance for easier-going providers. So, I don't "fit" anymore. Glad I lived below my means and saved.

Assuming a typical lifespan for my wife and I, we have approximately 240 months to live. Health status is reasonably good. We're going to live a life that makes US happy, which includes spending most of our time with family, friends, and generally people we like to be around, and avoid being around people we don't like to be around. And we're going to live a life that generally makes us happy.

I found this somewhere on the internet and I think it fits:

"First, I was dying to finish high school and start college...
Then, I was dying to marry and have children…
And then, I was dying for my children to grow up so I could work more…
But then, I was dying to retire…
And now I am dying….
And suddenly I realized I forgot to live.


To make money, we sacrifice our health,
and then to restore our health, we lose our money.
We live as if we are never going to die,
And we die as if we never lived….

Please don't let this happen to you.
This life is NOT a dress rehearsal.
Appreciate your current situation and enjoy each day.


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Author: bighairymike Big gold star, 5000 posts Old School Fool Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: 677353 of 744329
Subject: Re: Reflections of a Medical Ex-Practitioner Date: 4/10/2013 11:27 PM
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Anyway, I don't how to solve the problem either. But the moron politicians will never solve the problem. - beaconclks

---------------

Thank you for the insights in your reply. You point out some angles where a market solution seems impossible to construct. One thing we agree on is that meddling politicians will only make it worse.

We don't necessarily need a comprehensive solution to get started. I think a good place to start would be tort reform. Lets take the ambulance chasing, late night TV advertising, call 800 bad drug frenzy out of the picture. This alone takea a lot of defensive medicine out of the cost equationn. Reduces malpractice insurance rates too. Texas implemented tort reform a few years back and the wheels haven't come off here.

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Subject: Re: Reflections of a Medical Ex-Practitioner Date: 4/11/2013 1:17 AM
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Anyway, I don't how to solve the problem either. But the moron politicians will never solve the problem. - beaconclks

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Thank you for the insights in your reply. You point out some angles where a market solution seems impossible to construct. One thing we agree on is that meddling politicians will only make it worse.

We don't necessarily need a comprehensive solution to get started. I think a good place to start would be tort reform.


I think one of the root causes is the tax preference for third-party-paid medical-care insurance.

Premiums my hypothetical employer pays to provide me with insurance coverage, premiums I pay for that coverage, and actual payments to providers that I make, need to be treated EXACTLY the same way for tax purposes. Or if there is a tax preference, it needs to be in the opposite direction - relatively favoring out-of-pocket payments while relatively penalizing third-party-paid insurance.

I am not saying that this would be a sufficient change. And it certainly won't be rapidly effective - this cause dates back to the early 1940s and the pernicious effects didn't become readily apparent to non-economists until the 1970s or 1980s. But I think it's a necessary change, in that if we don't do it then whatever else we do will be inadequate and/or only temporarily effective.

We also need to take a serious look at all forms of government-provided medical care and insurance. Medicare as we know it is doomed; let's, in deciding how our elderly should get care, pretend it doesn't exist and design an economically rational system, THEN worry about how to get there from where we are. Medicaid, quite simply, I propose removing ALL federal requirements on the program and converting ALL federal funding of it to unconditional grants to the states, starting at a level equal to their last year before the change and then phasing out on a preset schedule.

And if we don't decide to dump Medicaid, maybe we should emulate Mexico's system: universal, free, lousy health care run by the government, alongside a private for-profit system of hospitals and doctors and pharmacies and insurers that is free to grow as much as the market will support - with neither tax/regulatory privileges nor tax/regulatory penalties.

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